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Austin’s stuff

Low-tech is sometimes superior

January 15, 2014 at 6:45 am

Aaron Carroll

Longtime readers of the blog know how much I hated residency. Most of my ire was directed towards my intern year. I like to think that while I struggled mightily at times my first year, I was a pretty darn good senior resident.*

One of the things I found absurd was the amount of documentation that we would have to create for each patient. When a child was being admitted from the emergency department my intern and I would head on down there to see him or her. Sure, they’d been seen already by a resident in the ED, as well as an attending physician, and sure, they already had notes written by both of them minutes before, but we still had to do our own. So we’d be expected to see the patient, take another history, and write two more notes. Later the attending would write another.

It was hard for interns, who would be expected to take the most thorough and complete of the admission notes. They’d be faced with a choice: either they could write as they talked to the patient, which meant they’d have to stop or break eye contact, or they’d have to try and remember everything to write a note later.

One of the things I decided to do early on was act as a scribe for them. It may have been “beneath” me, and it wasn’t something I was required to do. In fact, I don’t think many senior residents ever did it. But I found that if I wrote the intern’s note for them while they took the history and did the physical, it would improve the patient experience while also accomplishing our goals more efficiently. I was always about efficiency.

Amid the controlled chaos that defines an average afternoon in an urban emergency department, Dr. Marian Bednar, an emergency room physician at Texas Health Presbyterian Hospital Dallas, entered the exam room of an older woman who had fallen while walking her dog. Like any doctor, she asked questions, conducted an exam and gave a diagnosis — in this case, a fractured hand — while also doing something many physicians in today’s computerized world are no longer free to do: She gave the patient her full attention.

Standing a few feet away, tapping quickly and quietly at a laptop computer cradled in the crook of her left arm, was Amanda Nieto, 27, Dr. Bednar’s scribe and constant shadow. While Ms. Nieto updated the patient’s electronic chart, Dr. Bednar spoke to the woman, losing eye contact only to focus on the injured hand.

“With a scribe, I can think medically instead of clerically,” said Dr. Bednar, 40.

Evidently, there are something like 10,000 scribes working in hospitals around the country. They’re not as sexy as electronic health records, but they may make them better:

A study published jointly in October by the American Medical Association and RAND Corporation found that electronic health records were a major contributor to physician dissatisfaction, as doctors negotiate a cranky truce between talking to and examining the patient, and the ceaseless demands of the computer. And a recent article in the journal Health Affairs concluded that two-thirds of a primary care physician’s day was spent on clerical work that could be done by someone else; among the recommended solutions was the hiring of scribes.

“Making physicians into secretaries is not a winning proposition,” said Dr. Christine Sinsky, a primary care physician at Medical Associates Clinic and Health Plans, in Dubuque, Iowa, who also researches physician dissatisfaction.

I’m willing to grant that I was probably overqualified to be the scribe for my interns. But there’s no question my acting as one made things go so much more smoothly. I’m pleased to see that others are learning the same lesson.

*I’m going to open comments, but only so those of you who had the honor/misfortune to serve with me in residency can make a statement as to whether I was right or wrong about my abilities as a senior resident. Only comments on that specific topic will be approved. 🙂

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